Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice

Background: Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. Objective: Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. Design: This is a cross-sectional retrospective cohort study. Participants: A total of 3,705 patients met the study criteria. Main Measures: ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. Key Results: Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). Conclusion: The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.

Impact of Performance Status on Response and Survival Among Patients Receiving Checkpoint Inhibitors for Advanced Solid Tumors

PURPOSE Clinical trials, which led to the approval of immune checkpoint inhibitors (ICI), have been almost exclusively performed in patients with good Eastern Cooperative Oncology Group performance status (ECOG PS of 0-1). However, ICI remains an attractive option for patients with advanced tumors and poor PS. We hypothesized that patients with ECOG PS ≥ 2 would have worse outcomes with ICI. METHODS We retrospectively identified patients with advanced solid tumors who were treated with ICI at our institution. The log-rank test compared the survival among patients with different ECOG PS. We used a proportional hazards model to assess association between ECOG PS and overall survival (OS) with adjustment for covariates including age, sex, malignancy type, time from advance disease diagnosis, and line of therapy. We compared overall response rates between groups with Pearson chi-square exact test. We also analyzed in-hospital mortality and hospice referral rates. RESULTS We identified 257 patients treated with ICI. One hundred eighty-two patients had ECOG PS 0-1, and 75 had ECOG PS ≥ 2. The median overall survival was 12.6 months for the ECOG PS 0-1 group compared with 3.1 months for the ECOG PS ≥ 2 group ( P < .001). The overall response rate for patients with ECOG PS 0-1 was 23% compared with 8% for those with poor PS ( P = .005). Patients with poor PS treated with ICI had similar hospice referral rates (67% for ECOG PS ≥ 2 v 61.9% for ECOG PS 0-1, P = .50) but were more likely to have in-hospital death as compared with the good PS group (28.6% v 15.1%, P = .035). CONCLUSION Despite the appeal of ICI in patients with advanced malignancy and poor PS, outcomes in this cohort were poor. Prospective trials defining the activity and role of ICI in poor PS are urgently needed.

Documentation of goals of care (GOC) by medical oncologists is associated with improved oncology patient end-of-life (EOL) care outcomes.

1507 Background: Documenting GOC is integral to patient care and quality performance but has been underutilized by oncologists due to many barriers. As oncologists play a key role in initiating GOC discussions, we implemented a clinical initiative to improve their GOC documentation and evaluated the impact of such documentation on patient care during the EOL (last 30 days of life). Methods: We launched the initiative among 270 medical oncologists in an academic cancer center in 4/2020. A newly formulated GOC note to ease documentation was embedded in oncology outpatient and inpatient notes. Oncologists completed components in the GOC note that applied to their communication about GOC with the patient: 1) cancer natural history, 2) patient goals, and 3) EOL discussion: patient resuscitation preferences and, when pertinent, receptivity to hospice referral. GOC notes were pulled to a centralized location in the electronic health record (EHR) that displays documents relevant to patients’ values, goals and preferences. A dashboard allowed continual monitoring of documentation performance. We evaluated the association between GOC notes and outcomes of patient care at EOL. We further analyzed the impact of EOL discussion on EOL care. Results: The GOC note completion rate steadily rose after implementation. GOC notes were present in EHR for 46% of 10,006 patients who were either seen in outpatient clinic or discharged from hospital during the 1st week of January 2021. Among 1790 patients who died between 7/1/20 and 12/31/20 and had either at least an outpatient visit or hospitalization during EOL, the median days from first GOC note and first EOL discussion to the patient’s death were 71 days and 24 days, respectively. Linear regression analysis demonstrated that patients who had GOC note 60 days before death spent less time as inpatient during EOL (0.4 day less/patient, from 8.1 to 7.7, P = 0.01). When EOL discussion was documented 30 days before death, patients also spent less time in the hospital (1.2 days less/patient, from 9.7 to 8.5, P < 0.001) and in the ICU (0.3 days less/patient, from 1.7 to 1.4 ICU days, P = 0.04), and were 4% less likely to receive chemotherapy (from 38% to 34%, P = 0.004) at EOL. During the same period, among 1,009 patients with hospital admission in the last 30 days of life, those with a prior documented EOL discussion had shorter inpatient stay (7.7 vs 13.1 days, P < 0.001) and were more likely to be discharged to hospice (34% vs 22%, P = 0.003). Conclusions: During the COVID-19 pandemic, we successfully implemented GOC documentation by medical oncologists that is easily visible by the full care team. Documentation of GOC including EOL discussion was associated with fewer days in the hospital and ICU, increased hospice referral, and lower likelihood of receiving chemotherapy during patients’ last 30 days of life.

Patterns of presentation among New Zealand Māori with pancreatic cancer at Lakes District Health Board.

e18553 Background: New Zealand (NZ) Māori have higher rates of pancreatic cancer than other ethnic groups in NZ. Lakes District Health board (LDHB) has one of the highest proportion of Māori patients within New Zealand, 34.7% compared to 15.7% nationally. We aimed to review the patterns of presentation of patients diagnosed with pancreatic cancer at LDHB between ethnicities. Methods: Patients diagnosed with pancreatic cancer at LDHB between 01 Jul 2014 to 31 Mar 2020 were identified using the faster cancer treatment data and regional hospice referral data. This was cross checked against surgical and oncology referrals. Electronic notes were reviewed to collect data on ethnicity, patient demographics, & presentation. Results: 69 patients were identified; 25 Māori patients and 44 New Zealand European (NZE) patients. The mean age at diagnosis was 63.4 years for Māori and 73.4 years for NZE patients. 22 (88%) Māori patients were below the age of 75 at diagnosis compared to 24 (55%) NZE patients. In both groups there were more affected males than females. Risk factors such as positive smoking history, obesity and diabetes were more prevalent in Māori patients (80% v 43%, 40% v 16%, 44% v 20% respectively). Māori were more likely to present with metastatic disease compared to non-Māori at presentation (64% v 52%). Conclusions: Māori pancreatic cancer patients in our region were more likely to present younger with metabolic syndrome and more advanced disease compared to NZE patients.

Prognostic predictors relevant to end-of-life palliative care in Parkinson’s disease and related disorders: a systematic review

Parkinson’s disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life palliative care (hospice) than other illnesses, including other neurologic illnesses. Identification of predictors of PDRD mortality may aid in increasing appropriate and timely referrals. To systematically review the literature for causes of death and predictors of mortality in PDRD to provide guidance regarding hospice/end-of-life palliative care referrals. We searched MEDLINE, PubMed, EMBASE and CINAHL databases (1970–2020) of original quantitative research using patient-level, provider-level or caregiver-level data from medical records, administrative data or survey responses associated with mortality, prognosis or cause of death in PDRD. Findings were reviewed by an International Working Group on PD and Palliative Care supported by the Parkinson’s Foundation. Of 1183 research articles, 42 studies met our inclusion criteria. We found four main domains of factors associated with mortality in PDRD: (1) demographic and clinical markers (age, sex, body mass index and comorbid illnesses), (2) motor dysfunction and global disability, (3) falls and infections and (4) non-motor symptoms. We provide suggestions for consideration of timing of hospice/end-of-life palliative care referrals. Several clinical features of advancing disease may be useful in triggering end-of-life palliative/hospice referral. Prognostic studies focused on identifying when people with PDRD are nearing their final months of life are limited. There is further need for research in this area as well as policies that support need-based palliative care for the duration of PDRD.

Palliative care referrals in patients with advanced cancer on early-phase cancer clinical trials (EP-CTs).

29 Background: EP-CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the utilization of supportive care services, specifically palliative care (PC), in this population. Methods: We conducted a retrospective review of consecutive patients enrolled on EP-CTs at the MGH Cancer Center from 2017-2019. Sociodemographic and clinical variables, including utilization of PC services, were obtained via chart review. Details of the PC evaluation were compared between patients who received first referral to PC while enrolled on an EP-CT versus those who received a PC referral at any point after diagnosis. Results: Among 426 patients enrolled on EP-CTs (median age 63 years; 44% male), 249 (59%) received a PC referral at any time following a diagnosis of cancer (median age 57 years, 58% male). Eighty-six (35%) were referred prior to enrollment on EP-CT, 44 (18%) were referred while on EP-CT, and 119 (48%) were referred post-EP-CT. Patients referred on EP-CT were younger (median 56 vs 63 years, p < 0.0001) than those enrolled on EP-CTs. For patients referred while on EP-CT, 48% had a PC consult within 30 days of enrollment (range: 0-530 days); median number of PC visits was 3 (range: 0-37); median time from first PC consult to death or termination of EP-CT was 32 days (range: 1-213). Of 44 patients referred on EP-CT, 2 (5%) died while on EP-CT. Of the remaining patients, median time from first PC consult to date of death was 79 days (IQR: 45-178 days). Most common reasons for referral included pain (22, 50%), non-pain symptoms (21, 48%), and goals of care/advanced care planning (20, 45%). Of these referrals, 13 (30%) were initiated as inpatients versus 31 (70%) as outpatients. Pain was most commonly cited for outpatient referral (35%), followed by non-pain symptoms (25%) and goals of care (23%). Non-pain symptoms (40%) and goals of care (36%) were most commonly cited reasons for inpatient referral, followed by pain (24%). Of referrals while on EP-CT, 23 (52%) were made by EP-CT staff, including MD and APP, 7 (16%) from the primary oncologist, and 1 (2%) was self-referral. 26 (57%) of patients referred to PC during trial were also referred to hospice, with a median time from last PC consult to hospice referral of 24 days (range: -2-322). Conclusions: A majority of patients with advanced cancer enrolled on EP-CTs received a PC referral. The timeline and method of referral varied, but most patients did not receive a referral until or following enrollment on an EP-CT. Future work will focus on developing a standard referral protocol for patients enrolled on EP-CTs.

Physician perceptions about goals of care of hospitalized patients with malignancies.

e19234 Background: More sophisticated treatment techniques in cancer management have led to increased complexity in patient care. The perception of cancer outcomes is different between physicians and may result in premature hospice referral in hospitalized patients with or without cancer-related acute illness. We created a clinical scenario-based survey to assess perceptions of goals of care choices of inpatient primary providers while caring for patients with malignancies. Methods: A survey was developed and sent to all internal medicine and primary care residency programs nationwide via “Survey Monkey” online platform. Cases were adapted from real patient encounters. A total of 8 cases were presented and physicians were asked to determine level of care. Two cases represented potentially curable disease, three described patients with treatable but incurable malignancies, and the remainder described patients with advanced malignancies appropriate for hospice care. Physicians were also questioned about patterns of consulting hematology/oncology (HO) and their opinions regarding barriers in providing care to patients with malignancies. Results: Of 269 physicians who took the survey, 184 physicians (68%) fully completed it. 37% reported consulting HO for every patient with underlying malignancy, while 2% of the providers do not have access to HO consultants. In curable cancers, 65% of physicians would request inpatient oncology consultation while 11% would initiate hospice referral. There was a significant variation in choices for care in treatable cancer cases. In case 1, 13% of surveyed physicians thought that patients were hospice appropriate, while a higher percentage felt the same for the 2nd and 3rd cases with 18% and 52%, respectively. For hospice-appropriate patients, 25% of providers felt that further cancer treatment should be performed in younger patients, while the majority agreed on hospice referral (91%) for older patients. The most reported barrier to providing care to hospitalized patients with malignancies was a disconnect between the perception of goals of care of the primary treating oncologist/hematologist and patient’s actual condition. Conclusions: Perceptions about goals of care in hospitalized patients with malignancies varies and is affected by patient age and perceived severity of disease, which doesn’t necessarily translate into outcome statistics reported in literature. A multidisciplinary approach and treating oncologist involvement might be warranted when patient goals of care change is planned in hospital setting.

End-of-life care in the immune checkpoint inhibitor era.

e24003 Background: Immune checkpoint inhibitors (ICI) can lead to durable responses in some patients with advanced non-small cell lung cancer (NSCLC) with less toxicity than chemotherapy. However, ICI can cause idiosyncratic adverse effects and radiographic responses can be difficult to interpret, making prognostication difficult and potentially impeding a timely transition to hospice. Our purpose was to explore end of life (EOL) outcomes in NSCLC patients treated with ICI. Methods: Retrospective data were collected on all patients with NSCLC started on ICI at single center (2014-2018) and who died before last known follow-up. EOL outcomes included hospitalizations, ICU admissions, timing/location of hospice referral and death. Charts were reviewed to identify barriers to hospice referrals or enrollment. Outcomes were compared to published data of similar cohort (2008-2010) from same institution treated with chemotherapy. Results: Out of 143 patients who died, 83 (58%) had internal hospice referral by cancer center; 15 (11%) were referred by external provider. Hospitalization frequency was associated with higher likelihood of internal hospice referral (p 0.04). Internal hospice referral was not associated with differences in age, sex, race, ethnicity, smoking history, cancer subtype, treatment response/toxicity, or overall survival. Internal hospice referral was associated with decreased rates of death on the hospital floor (p < 0.001) and the intensive care unit (ICU, p < 0.001). When compared to chemotherapy cohort, there was similar rate of hospice referral (68% vs. 74%, p 0.33) but higher rates of starting new systemic therapy within 30 days of death (17% vs. 6%, p 0.001) and last dose within 14 days of death (13% vs. 5%, p 0.005). Other EOL outcomes (hospitalization frequency, death in ICU) were similar, although ICI cohort trended towards a lower rate of death on the floor than chemotherapy cohort (16% vs. 25%, p 0.06). Barriers to hospice referral were not well documented by providers but lack of family support for home EOL care was a common reason patients declined hospice. Conclusions: ICI was associated with a higher rate of systemic treatment at EOL as compared to a historical chemotherapy cohort, although the rates of hospice referral and other outcomes were similar.